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Generalised Anxiety Disorder

The main feature of generalized anxiety disorder (GAD) is excessive and difficult to control worrying. The content of worry is not confined to one particular thing but is more general and the worry-topic can move around from one theme to another. Worry is a chain of negative thoughts involving themes of threat or danger in the future. It usually consists of “what if..?• type questions and dwelling on the possibility of future harm and ways to prevent or avoid it.

In addition to the problem of excessive and uncontrollable worry, GAD consists of a minimum number of additional anxiety symptoms. At least three of the following symptoms should be present: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance. Fewer than 3 symptoms may be present at times because GAD is worse during times of stress. Muscle tension and sleep disturbance are the most common symptoms.

Because worry is a feature of many types of psychological problem it is necessary to ensure that the worry is generalized and not linked solely to another anxiety disorder. For example, if worries concern acting in a way that is embarrassing and the person has social anxiety disorder and there are no other worry domains this is likely to be social anxiety rather than GAD.

In GAD the anxiety and worry causes significant impairment and distress and occurs more days than not for at least 6 months. If the worry and anxiety does not meet these criteria then sub-threshold GAD or GAD in partial remission may be an appropriate label.

Excessive anxiety and worry can occur as a result of certain medical conditions (e.g. hyperthyroidism) or the result of substance abuse or toxins. Heavy caffeine consumption can also produce anxiety symptoms such as restlessness, sweating, agitation and sleep disturbance. If you are suffering from excessive anxiety or worry it is sensible to reduce the use of non-prescription drugs and caffeine. You should consult with your doctor to rule-out any possible medical conditions that might be causing your symptoms.

Treatment

Over the years different treatments for GAD have been tried and evaluated. The main ones have been: Anxiety Management, Behaviour Therapy, and Cognitive Behaviour Therapy.

Anxiety management therapies consist of learning methods to control anxiety such as relaxation, distraction and coping skills. Behaviour Therapy has typically involved structured relaxation training and application of relaxation to stressful situations. Cognitive Behaviour Therapy (CBT) consists of combinations of relaxation training and challenging negative thoughts and worries. The best of these treatments are behaviour therapy involving applied relaxation and CBT. Across studies applied relaxation leads to recovery rates of around 34 per cent. The combined recovery rates across CBT studies are around 46 per cent. However, there is a wide range across different studies.

These figures leave much room for improvement. One of the limitations of earlier treatments was a lack of an understanding of the underlying factors driving uncontrollable and excessive worry. At MCT-I we have been working on new treatment:-Metacognitive therapy (MCT) which is based on a tested model of the causes of pathological worrying. This treatment is brief and consists of identifying and challenging underlying beliefs about worry and learning new and more effective ways of relating to negative thoughts. This treatment has been shown to lead to recovery rates of 70-80 per cent.

Drug treatment has also been used in GAD. Early treatments consisted of benzodiazepines but it is generally agreed that these should not be used long term. In the short term they produce side effects of sedation and fatigue and in the long term are associated with problems of dependency. Antidepressants, specifically some of the Selective Serotonin Reuptake Inhibitors (SSRI’s) have been found to improve symptoms. However, evidence suggests they have a minor effect on worry which is a key aspect of the problem.

Metacognitive Therapy (MCT) or CBT is recommended as the first choice in treating GAD.

References

Borkovec TD & Costello E (1993). Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 61, 611-619.

Fisher P (2006). The efficacy of psychological treatments for generalised anxiety disorder. In G C L Davey & A Wells (eds), Worry and its psychological disorders: Theory, assessment and treatment. Chichester, UK: Wiley (pp. 359-377).

Wells A (1997). Cognitive therapy of anxiety disorders: A practise manual and conceptual guide. Chichester, UK: Wiley. (Chapter 8-metacognitive therapy treatment manual for GAD).

Wells A (2008). Metacognitive Therapy for Anxiety and Depression. New York: Guilford Press.

Wells A & King P (2006) Metacognitive therapy for generalized anxiety disorder: An open trial. Journal of Behavior Therapy and Experimental Psychiatry, 37, 206-212.

Wells A et al (in preparation). Metacognitive therapy versus applied relaxation in the treatment of GAD: A randomized trial.